non-visual effects: myth or truth - energy.gov...dezentrales logo optional slide 12 voelker, s....

Prof. Dr. Stephan Völker, Inga Rothert | Department Light and Lighting

Non-visual effects: Myth or Truth

Billd: www.giga.de

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Content

1. Background of German Engagement for the LED

2. Practical using – two point of views

3. DIN SPEC 67600

4. Project NiviL on the University of Technology Berlin

5. Consequences and Outlook

Non-visual effects: Myth or Truth | Prof. Dr. Stephan Völker, Inga Rothert

Slide 2

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Content

1. Background of German Engagement for the LED


Slide 3

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LED = One of the leading markets for

Germany

Research budget (2008 – 2015): 40 € million for

technology and pilot projects

plus 50 Mio € for promotion of projects in the

municipalities

Reasons

1. LED technology is ready for using – no

reasons to wait longer!

2. permits energy savings between 50 - 90 %

3. improvement in lighting


Slide 4

1. German Engagement for the LED

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optional Non-visual effects: Myth or Truth | Prof. Dr. Stephan Völker, Inga Rothert

Slide 5

2. Value added of the LED

• Visual effects

• emotional effects

• non-visual effects

= Human centric

lighting (HCL)

Remark:

Non-visual effects

– only one aspect

of HCL!

health

circadian rhythm

emotion

Visual

performance

Light for a

high quality

of life

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Content

1. Background of German Engagement for the LED – LED

Leading market

2. Practical using

a. Industry

b. Office

c. Schools

d. Nursery homes and hospitals

e. Residential and hotels

– two point of views


Slide 7

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Content


Leading market



Slide 8

One side:

Industrie:

• want to create new Products

with added value

• Have to invest in

knowledge, new processes

Other side:

Custemer:

• Doubtfull

• Experience: Not every

product fulfills this

promise!

http://www.lightingeurope.org/uploads/files/Quantified_Benefits_of_Hum

an_Centric_Lighting_April_2015.pdf

http://www.lightingeurope.org/uploads/files/Quantified_Benefits_of_Human_Centric_Lighting_April_2015.pdf

http://www.lightingeurope.org/uploads/files/Quantified_Benefits_of_Human_Centric_Lighting_April_2015.pdf

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Needs further research!

Market study from ZVEI/ ATKearney


Highly sensitive to Assumptions

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Non-visual effects:

Slide 10

health

circadian rhythm

emotion

performance

jet lag

office

hospital

retirement home

school

industry

well-beeing

sleep quality

quality of life


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Voelker, S. Dissertation, Ilmenau 1999


Industry (1)

Illuminance /lx

950 - 1049850 - 949

750 - 849650 - 749

550 - 649450 - 549

350 - 449250 - 349

150 - 250

1615

14

13

12

11

10

9

8

7

6

5

43

2

10

Typ of accident

Sprain, bruise, bump

Fracture

Get one’s hand caught

Cut and other wounds

Scald, burn

Light and accidents

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Montage-

arbeitsp latz

Meß-

arbeitsp latz

Bohr-

arbeitsp latz

Labor-

arbeitsp latz

Elektro-

arbeitsp latzarbeitsp latz

Sortier-

Voelker, S.; Dissertation 1999

• Dependent variables: performance, errors, acceptance (questionnaire),

alertness (highest hear and flicker frequency)

• Independent variable: illuminance (30, 100, 200, 600 lx)

• Test design: short-term lab

tests, 8 work places a 10 min

(in sum 2 h) N = 40, long- term

lab test 8 h, N = 12

• Field test, 130 workplaces in

Metal- and Electro-Industry

Industry (2)

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Short-term test – 2 hours

Industry (2)

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Long-term test – 8 hours

Industry (2)

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Voelker, S. Dissertation,

Ilmenau 1999


2500-50001200-2500

900-1200700-900

500-700300-500

200-300100-200

0-100

4

2

0

-2

-4

E in lx

• Light level between 300 - 500 lx: acceptable

• Optimal light level: 700 – 1500 lx

• Similar results of Halonen, Tenner, et al.

bad

accepta

ble

o

ptim

al Wished light level (field test – 130 work places)

Industry (2)

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1. Fixed light level: 50 or 1700 lux higher productivity 3%

lower absenteeism -17%

2. Fixed light level: 800 or 1200 lux higher productivity 3%

3. Fixed light level: 500 to 1050 lux higher productivity 5.5%

lower absenteeism -2.5%

Juslen, H., 2008

Method: Field Studies in the Industrial Environment

4. Personal light: 100 – 3000 lux higher productivity 4.6%

5. Personal light: 100 – 900 lux,

fixed colour temperature

3500 K or 4400 K higher productivity 5.7%

• a wide range of preferred illuminances

• employees like to have personal lighting control possibilities

Industry (3)


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Canazei & Dehoff (2013, Zumtobel Research):

• Dependent variables: performance (processing time per piece)

• Independent variables: Dynamic change in brightness: 1000 – 3000 lx vs.

static 1000 lx

• Test design: field test in industrial Company Flexitronics, each 1 week

changed, 3x randomized repeated, N=14

• Result: in winter: 4% shorter relative processing time per piece, not in

summer, Difficulties to measure productivity


Industry (4)

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References Market Study - Industrial

Additional results in the literature review from van Bommel, van den Beld & van

Ooyen (2002, Philips):

ATKearney Scientific based

Better task performance 16 % (300 lx -> 2000 lx) depending on task

5 – 50 %

Reducing of errors 30 %

higher alertness 50 % difficult to measure

Less Accidents 50 % for low light level

higher productivity 15-20% depending on task

5 – 50 %


Industry

Summary

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References?

Condition: much more

precisely lighting design


Industry

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Non-visual effects:

Slide 21

health

circadian rhythm

emotion

performance

jet lag

office

hospital

retirement home

school

industry

well-beeing

sleep quality

quality of life


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Office (1)

Aries, 2005:

• Dep. variables: Fatigue, sleep quality (questionnaire)

• Indep. variables: vertical Illuminance

• Test design: field study with office workplaces

• Results:

• Only 20 % of workplaces have more than 1000 lx

• people who worked under lower vertical illuminance levels

reported significantly more fatigue and worse sleep quality

than people working under high levels of vertical illuminance,

also when adjusted for gender, age, eye correction, seasonal

sensitivity and chronotype.“

Slide 23


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Office (2)

Mills, Tomkins & Schlangen (2007, J. of Circadian Rhythms)

• Dependent variables: alertness/concentration/sleepiness (self-

questionnaires - modified Columbia Jet Lag Scale), performance (item from

WHO-HPQ), health (SF-36)

• Independent variables: Color Temperature (2.900 K vs. 17.000 K)

• Test design: 1 floor of a call center gets new 17.000 K (= Intervention), 1

floor stays with 2.900 K (= Baseline), N = 69, questionnaires at beginning,

after 7 and 14 weeks during the working hours

• Result: 26-37% improvement of concentration and alertness from Columbia

Scale, 19 % better work performance from WHO-HPQ, 14 % better mental

health from SF-12 and good acceptance

• intervention group in contrast to baseline group

• Discussion: uneven numbers of test persons in the groups, seasonal effects

possible, visible difference in light colors people talk


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Office (3)

Slide 25


Viola et al. 2008

• Dep. variables: Alertness,

Performance, evening

fatigue, PSQI

(questionnaire)

• Indep. variables: TF 3000 K

(yellow) vs. 5000 K (blue)

Illuminance 500 – 900 lx

(variable)

• Test design: field test

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Office (3)

Viola et al. 2008

• Dep. variables: Alertness,

Performance, evening

fatigue, PSQI

(questionnaire)

• Indep. variables: TF 3000 K

(yellow) vs. 5000 K (blue)

Illuminance 500 – 900 lx

(variable)

• Test design: field test

• Results: Cool white light

during the working hours on

day improves the subjectiv

alertness, performance und

increase the fatigue

Slide 26


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de Kort, 2009

• Dep. variables: recovery, vitality, sleep quality, mental health, headache and

eyestrain, subjective performance

• Indep. variable: Comparison between dynamic lighting (500 – 700 lux, 3000 –

4700 K) and static lighting (500 lux, 3000 K) with the same installation

• Repeated manipulation of the dynamics

• Four parallel groups: 2 long term (change once per year) and 2 short term

(change once per month), Monthly measurement (web-based questionnaire)

(wk 3)

• Results:

• No significant differences in workers' need for recovery, vitality, sleep

quality, mental health, headache and eyestrain, subjective performance,

controlled for relevant personal, job and work related characteristics.

• Workers in dynamic lighting did report being more satisfied with the

lighting condition


Office (4)

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Office (5)

Shamsul et al., American J. of Public Health Research, 2013

• Dep. Variables: Performance: visual acuity and contrast (frACT-test, with

Landolt rings), Self assessment KSS, Office Lighting Survey

• Indep. variable: Color temperature (WW 3000 K, CW 4000 K, DL 6500 K)

• Test design: randomized sequence of CCTs in an experimental room

without daylight, N = 47

• Results: 6500 K best performance

4000 K most comfortable


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Office (6)

Smolders et al., Journal of Environmental Psychology, 2014

• Dep. variables: attention self assessment, Karolinska Sleepiness Scale (KSS: 1 -

9), auditory concentration task (PVT and Go-NoGo)

• Indep. variable: Ev = 200 & 1000 lx, groups: fatigue vs. control

• Test design: 2x2 within subjects design, same daytime per person, no daylight

contribution, N = 28


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• Dep. variables: attention self assessment, Karolinska Sleepiness Scale (KSS),

auditory concentration task (PVT and Go-NoGo)

• Indep. variable: illuminance(200 lx vs. 1000 lx), fatigue vs. control



• Results: Improvement of sleepiness and vitality at 1000 lx, especially with tired

test persons


Office (6)

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• Dep. variables: attention self assessment, Karolinska Sleepiness Scale (KSS),

auditory concentration task (PVT and Go-NoGo)

• Indep. variable: illuminance(200 lx vs. 1000 lx), fatigue vs. control



• Results:

• Improvement of sleepiness and vitality at 1000 lx, especially with tired test

persons

• PVT: 1000 lx positive influence on reaction times, but not significant

• Go-NoGo: 1000 lx leads to significant slower reaction times strong task

dependence


Office (6)

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Office (7)

Möller et al., LICHT 2014:

• Dep. variables: acceptance and well-being

(questionnaire), concentration and performance

test (KLT-R), sleep quality (heart rate variability)

• Indep. variable: 2 spectra: LED and fluorescent

lamp

• Test design: 500 lx @ eye and 4000 K with same

experimental procedure (simulated office day)

• Results:

• LED effects more comfortable

• Positive effect on sleep quality in following

night

• No differences in performance and well-

being

Slide 32

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lighting

/


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References Market Study - Industrial

ATKearney Scientific based

Productivity 1,5 – 19 % 0 – 10 % depending task

Alertness +

Concentration 0 - 30 % can be, by a strong change

Sleepiness 0 - 10 % for the group of tired test subjects,

but for a strong increase of illuminance

Satisfy with light 0 – 30 %

Sick days - 1 % Possible, but assumption

Better well being + Probably yes

Longer staying + 1 year Possible, but assumption


Light for the office

Summary

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References?


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Non-visual effects:

Slide 35

health

circadian rhythm

emotion

performance

jet lag

office

hospital

retirement home

school

industry

well-beeing

sleep quality

quality of life


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Schools (1)

Barkmann et al., Physiology & Behavior, 2012, Hamburg

• Dep. variables: concentration (D2-test), reading speed and comprehension

(ELFE 1-6 / LGVT 6-12), attitude to school and subjective evaluation (self

questionnaire)

Billd: licht.de


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Schools (1)


• Dep. variables: concentration (D2-test), reading speed and comprehension

(ELFE 1-6 / LGVT 6-12), attitude to school and subjective evaluation (self

questionnaire)

• Indep. variables: 3 light scene: standard lighting (300 lx, 4000K), light for

high concentration (1000 lx & 5800K), variable light (275 lx .. 1000 lx &

3500K .. 11000K)

• Test design: intervention and control classrooms in 2 schools, 45 min test

sequence at beginning (both standard lighting) and after 4 weeks (standard

vs. concentrate), at beginning and after 9 month questionnaires for long-term

effect, N = 116

• Results: no long-term effects, but 70%

of students recommend variable

lighting

Billd: licht.de


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• Results: D2-test 20% less errors, 17% improved reading speed

• Do not forget STD:


Slide 39

Billd: Barkmann et al. 2012

Schools (1)

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Billd: licht.de

Wessolowksi et al., Journal of Environmental Psychology 2014, Hamburg

• Dep. variables: fidgedtiness (Move-it camera: counts varying pixel,

long-term: Conners Rating Scales), Aggression (independent experts

evaluate video, long-term: aggressiveness of youth self-report)

• Indep. variables: 3 Light scenes: standard lighting (300 lx, 4000K),

‘relax lighting’ (325 lx, 3500K), ‘dynamic lighting’ (275 lx .. 1000 lx,

3500K .. 11000K)

• Same Test design like before


Schools (2)

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Wessolowksi et al., Journal of Environmental Psychology 2014, Hamburg

• Results: Fidgetness and aggression decrease with ‚Relax lighting‘, but no

long-term effects


Schools (2)

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Schools (3)

Keis et al., Trends in Neuroscience and

Education, 2014, Ulm

• Dep. variables: concentration (D2-Test,

numbers combining test)

• Indep. variables: spectrum and light

distribution

• Blue enriched light (LED: 4000K direct,

14.000K indirect) vs. standard light

(fluorescent lamps only direct 3000K

(school 1) or 4000K (school 2))

• Testdesign: N = 58, 12. grade, 2 school

classes in 2 schools, 5 weeks longterm

illumination x acute test conditions

• Result:

significant improvement of

concentration with blue enriched

light


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optional Slide 43

Cognitive performance improved

Impact on GDP


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Non-visual effects:

Slide 44

health

circadian rhythm

emotion

performance

jet lag

office

hospital

retirement home

school

industry

well-beeing

sleep quality

quality of life


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optional Slide 45


Highly sensitiv to assumptions!

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Elderly (1)

Billd:Philips

Bieske et al. LuG 2006, N = 6:

• Dep. Variable: vitality, orientation, emotional stability, sleep quality

(questionnaire of care staff)

• Indep. Variable: 50 lx Eeye, 2800 K 1800 lx, 6000 K

• Results: Improvement of vitality, orientation, emotional stability, sleep quality

Billd: Bieske et al. 2006


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Elderly (2)

Riemersma et al., JAMA, 2008, N =

189:

• Dep. Var.: sleep quality, a.other

• Indep. Vari.: Increased illuminance

(300 vs. 1000 lx Eeye) by the use of

an illuminated ceiling

Billd: Bieske et al. 2006


• Results: increased sleep quality

(Actigraphy)

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Elderly (2)

Riemersma et al.,

JAMA, 2008, N = 189

Results:

• decreased

depressive

symptoms (Cornell

Scale)

• Delayed cognitive

deterioration by

dementia (Mini-

Mental-State),


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optional Slide 49


Probably yes, but to less studies!



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Non-visual effects:

Slide 50

health

circadian rhythm

emotion

performance

jet lag

office

hospital

retirement home

school

industry

well-beeing

sleep quality

quality of life


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Residential (1) – Wellness hotel

Wojtysiak, A., LICHT 2014:

• Dep. variables: melatonin and

cortisol concentration, heart rate

variability, Sleepiness (KSS),

sleep quality (PSQI, movement

sensor, step counter),

questionnaires acceptance/

well-being

• Indep. variables: illuminance,

spectrum, Timing

• 30-50 lx 700-2000 lx @ eye

• 1700-2800 K 4000-6800 K

• Test design: simulated week-

end stay, N = 84

Slide 52

A. Wojtysiak, Osram, Vortrag LICHT 2014, Den Haag, NL


Reference =

standard lighting

Interference =

chronobiological

optimisation

Concept

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Residential (1) – Wellness hotel

• Results: significant improvement of acceptance and sleep quality

Slide 53

A. Wojtysiak, Osram, Vortrag LICHT 2014, Den Haag, NL


Wake up

Morning

Day

Evening

Night

Movement

Self-report

Sleepiness Acceptance Sleep

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Residential (2)

• Dep. variables: melatonin

concentration (saliva), Daysimeter

• Indep. variable: spectrum (use of

orange glasses or not)

• Test design: usage of self luminous

devices (tv, pc, tablet..) 3h before

bedtime

• N = 20, adolescents 15-17y

• Result:

• Using the devices suppressed

melatonin about 23%

• Adolescents are more sensitive

(compare Figueiro et al. 2011 with

students)

Figueiro u. Overington 2015


Figueiro u. Overington, Biological research for nursing, 2015

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Content


Leading market


a. Office and Industry

b. Schools

c. Nursery homes and hospitals

d. Residential and hotels

e. Airplanes

3. DIN SPEC 67600




Slide 56

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optional Non-visual effects: Myth or Truth | Prof. Dr. Stephan Völker, Inga Rothert

Slide 57

DIN Spec 67600:2013-04

Expected positive effects:

• Stabilization of individual circadian rhythm

• Support the amplitude of biological clock

• Activation and improvement of concentration

• Stabilization of motivation and decrease of sleepiness

• Enable and promote regeneration

• Improvement of mood, well-being (e.g. avoid depression)

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Parameters which influence the biological effects:

• Irradiance

• Duration

• Spectrum (blue part)

• Light distribution

• Dynamic changes

• Light history

• Daytime

Recommendation for biological active

light:

Ev at the eye ≥ 250 lx, CCT= 8000K

Ev at the eye ≥ 290 lx, CCT= 6500K


Slide 58

Billd: © “Biologisch wirksame Beleuchtung - Planungsempfehlungen” –

Wojtysiak, Fassian, Greiner Mai, Scharpenberg – Biowi 2013

Illuminance Melanopic weighted irradiance

Light sources

Luminaires

Light distribution

Spectrum

Timing

DIN Spec 67600:2013-04

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Planning recommendations

• Educational institutions and schools

• Offices

• Control rooms

• Retirement homes

• Medical facilities

• Residential places

• Hotel rooms

• Shift work


Slide 59

DIN Spec 67600:2013-04

1. Intended biological effects refer to daylight, artificial light or a

mixture of both

2. Planning recommendations additional to visual requirements

of other standards (DIN EN 12464-1, ASR A3.4)

3. Voluntary

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Planning recommendations

• Educational institutions and schools

• Offices

• Control rooms

• Retirement homes

• Medical facilities

• Residential places

• Hotel rooms

• Shift work


Slide 60

DIN Spec 67600:2013-04

1. Intended biological effects refer to daylight, artificial light or a

mixture of both

2. Planning recommendations additional to visual requirements

of other standards (DIN EN 12464-1, ASR A3.4)

3. Voluntary

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Planning recommendations for specific applications as tables:

+++ Use of biological active light is recommended

++ Use usually recommended; exceptions possible e.g. not constantly occupied

workplaces

+ Use generally not required

DIN Spec 67600:2013-04


Slide 61

Dynamic light adapted

on the course of day

Lecture halls

Blackboards, whiteboards

Class rooms, seminar rooms

Class room for evening classes and adults

Demonstration table

Art room

Type of the room, the task

or the area of task Specific conditions Relevance

for design

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I. Dynamic lighting for schools

Useful dynamics, but every situation needs individual planning


Slide 62

a) Dynamic like natural Daylight

CCT [K] CCT [K] E [%] E [%]

Dynamic supports activation

Daytime Daytime

DIN Spec 67600:2013-04

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II. Dynamic lighting in retirement homes:


Slide 63

Vertical illuminances:

1. 200 lx and 3 000 K

2. Illuminance level depending

on the viewing task

3. 250 lx and 8 000 K

DIN Spec 67600:2013-04

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DIN SPEC 5031-100:2015-08

Definition: Melanopic effect of light


Slide 64

Calculation of melanopic radiant quantity

Tables for smel (λ) based on Lucas, 2014

830

,

380

( )

nm

mel v e mel

nm

X X s d

830

380, 830

380

( )

( )

nm

e mel

nmmel v nm

e

nm

s d

a

V d

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DIN SPEC 5031-100:2015-08

Definition: Melanopic effect of light


Slide 65

Calculation of melanopic radiant quantity

Tables for smel (λ) based on Lucas, 2014

830

,

380

( )

nm

mel v e mel

nm

X X s d

830

380, 830

380

( )

( )

nm

e mel

nmmel v nm

e

nm

s d

a

V d

Attention: mel-lm or mel-lx is not allowed!

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DIN SPEC 5031-100:2015-08


Slide 66

With Correction factors:

Demands on lighting design describtions of light exposure

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Content


Leading market

2. Value added of the LED

3. Non-Visual Effects one aspect of HCL – background



b. Schools



e. Airplanes

5. DIN SPEC 67600



Slide 67

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Project NiviL:

• Project: Build a model, define stimulus, specify thresholds values

Slide 68

Ge

ne

tics

C5

Jo

b s

itu

atio

n C

7

He

alth

sta

tus C

6

E1 Brightness

E2 Spectral distribution

E3 Spatial distribution

E4 Time of day

E5 Static vs. dynamic lighting

Melatonin suppression A1

Cortisol concentration A2

Attention A3

Stress perception A4

Sleep qualtiy A5

Pain perception A6

Ag

e

C1

Ch

ron

oty

pe

C

2

Str

ess typ

e C

3

Model

Well-beeing A7

Ind

ivid

ua

lity C

4


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I. Determination of threshold values

• Dep. variables: melatonin, cortisol concentration, sleep quality,

Attention (Audio task, D2, KSS),

• Indep. variables: Different spectra, age, gender, stressed vs. not

stressed, bipolar disorder vs. healthy

• Method: half sphere (evening: 20 – 01 o’clock)

Slide 69

Used by

Bild: Kugeln von Falk Wieland Bild: LED-Platine von Falk Wieland


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optional

II. Field study in a retirement home

• Dep. variables: well-being, quality of life and activity

• Indep. variables: Different spectra and illuminances and dynamics

• Method: Fieldstudy, elderly people pre-post comparison, N = 120

Slide 70


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III. Laboratory study (TU Berlin)

• Dep. variables: Attention (Audio task, D2, KSS), acceptance of

illumination

• Indep. variables: Different spectra and illuminances

Slide 71

Bild: Kugeln von Falk Wieland Bild: LED-Platine von Falk Wieland


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IV. Field study in a lecture hall (TU Berlin)

• 90 min lecture under diff. lighting

settings

• Attention test D2, self evaluation

questionnaire KSS, cortisol

• Lighting: RGBW- fluorescent lamps

• Settings prepared in laboratory

validation in the field

• Indep. variables:

Illuminance @ eye, CCT

• Dep. Variables:

Attention (D2-test, KSS), acceptance,

cortisol

Slide 72


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optional

Project NiviL:

• Project: Build a model, define stimulus, specify thresholds values

Slide 73

Ge

ne

tics

C5

Jo

b s

itu

atio

n C

7

He

alth

sta

tus C

6

E1 Brightness

E2 Spectral distribution

E3 Spatial distribution

E4 Time of day

E5 Static vs. dynamic lighting

Melatonin suppression A1

Cortisol concentration A2

Attention A3

Stress perception A4

Sleep qualtiy A5

Pain perception A6

Ag

e

C1

Ch

ron

oty

pe

C

2

Str

ess typ

e C

3

Model

Well-beeing A7

Ind

ivid

ua

lity C

4


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Content


Leading market



b. Schools



e. Airplanes

3. DIN SPEC 67600




Slide 74

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optional Slide 75



Conclusion

1. Illuminance level has different influence on different task --> different

light level will have different effects on different non-visuell effects

2. Time duration of the test has an significant influence on the result! We

need long-term experiments with more test subjects in different areas

3. Field experiments show a wide spread (a lot of disturbance variables)

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What training is required?

1. Knowlage about light and lighting (correct handling with the terminology)

2. Understanding that a design for non-visual effects has more dimensions

than brightness!

1. Vertical radiation (Illuminance) on the retina combined with

2. Right spectrum and

3. Right timing!

3. Individuals are different – where it is possible – use personal control

4. Deal with perception – standards base on old technology – use the

possibility to create an adapted lighting design for the specific task


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Where do we need more information?

1. Data basis for threshold values (Ex) and limits are thin! – Experiments with

larger groups of test subjects are necessary!

2. We need more long-term experiments!

3. Systematic description of the Influence of control variables

4. Which risks do exist for special typs in our population (chronotyp owl) with a

wrong timing?


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Research agenda

What research still has to do:

• Light in the ‘Black box’ Background knowledge

• Definition of threshold values and limits

• Investigation about interactions between E and C variables

• Investigation about interaction between the different receptor typs –

Do we use the right spectral sensitivity? • Risk for night shift workers


Picture: Olafur Eliasson – the

Weather Project Tate Modern

(2003 – 2004)

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Use LED, then you can

• Save a lot of Energy!

• Improve your lighting Quality through

– Adapted lighting levels

– Adapted lighting distribution

– Adapted spectral distribution

• Lighting is an important factor … - use it!

• Improve the situation in the industry, offices, schools, nursery homes and

hospitals for a better life!

… but don‘t believe everthing!


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Thank you!

Slide 80


non-visual effects: myth or truth - energy.gov...dezentrales logo optional slide 12 voelker, s....

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